Chapter 1
Planning Hospitals
of the Future
Richard Sprow, AIA
Over the last 60 years, there have been recurring
trends in thinking about the planning and design of
hospital facilities, which seem to go through cycles.
Specialty hospitals, new standards for patient
rooms, ideas for efficient nursing unit planning, and
design for healing environments; all have been the
subject of architectural thinking in the past and then
interest has subsided – but all will certainly be back
again. As planners in one of the world’s largest
healthcare design practices, we spend every day
talking with hospital managers about future planning
issues, which are often linked to marketing
responsiveness, new technologies, and changing
expectations about healthcare delivery.
Ten Ideas Driving New Hospital Planning
Rethinking patient flow in hospitals to improve
the patient experience and make operations more
efficient. With more digital information being shared
around the hospital network, and the desire for a
patient visit which is as seamless and direct as
possible, hospitals are now looking beyond
departmental borders to think about how patients
make appointments, how they arrive at the right
location for their visit, and how clinical and financial
information is captured and processed. Instead of
an older departmental organization, along the lines
of the now-vanished large department store,
hospitals are thinking about providing service
concierges to direct patients, providing
central registration points to capture basic
information for the database only once, and
using computer-assisted scheduling and
management systems that track patient
arrival times, length of wait, and final results.
Having this information makes possible
management analysis and responses to
smooth the flow. The next step in this process
may be like more advanced retail uses,
where the information on arrival and wait time
is displayed to customers and any response
beyond the stated goal gets them an apology
and a reward.
Integrating information technology is the
other side of this operational point of view.
From concerns only few years ago that
clinical staff would never use a keyboard, we
now see computers as an essential fixture
at every point of patient contact, often as part
of a wireless network linked to staff smart
phones and communication systems. Old
technology like the nurse call system can now
be part of the network, linked to data
collection and faster response. From a facility
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point of view, the need is for more space –
the “paperless” environment replaces
clipboards and forms and rooms full of paper
files with more computers, keyboards, server
closets, printers, shredders, and fax
machines, plus storage for all of their
supplies.
Wayfinding is more than signs.
A stronger management concern for the
patient experience, as part of a market share
focus, means that old systems such as
endless standard signs (and even worse,
colored stripes on the floor) are being
replaced by more information, more
interactive systems. Electronic kiosks,
computerized direction systems, and
planning that is clear and modular, even
without signs, are the new tools in helping
patients and families navigate the hospital
and to make it more accessible to them.
Dealing with flexibility and change –
repeatedly. Hospitals are unique in being a
building type with a long overall useful life
but a very short lifetime for specific rooms.
Unlike commercial or educational facilities,
hospitals are routinely used for 50 years or
more – but at the same time individual rooms
may be changed or replaced after as few as
seven years, as clinical methods and
equipment change. The challenge is to plan
for ease of use, good wayfinding, high
technology and a healing environment, but
without assuming that specific rooms will
remain unchanged for very long. Hospitals
are responding with an acceptance of more
generic and modular space, much less likely
to be customized to the needs of specific
service or a particular donor’s desires.
Today’s pediatric exam room may later be
part of a geriatric cardiology unit, or a new
imaging suite, or relocated office functions
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in only a few years. Often it is more flexible and
efficient to build a smaller number of larger but
standardized room.
Interior design standards and a systematic
approach. The need to plan for and facilitate rapid
change means that hospital interior design must also
reflect a broader, more flexible approach, so that
new and renovated and existing parts of one facility
can co-exist and look like parts of one coordinated
institution. Creating and maintaining design
standards is an important tool in creating this unified
look. Housekeeping staff is now often involved early
in evaluating maintenance of materials and agreeing
to choices that can be kept at a high standard over
the long term. Hospitals are large facilities in
constant evolution, so their interiors must be able
to blend with the times and to deal with change in
small increments. Unlike hotel or retail
environments, a partial closure to allow one new
look to be implemented is never an option, and the
true 24 hour/7days a week /365 days a year
healthcare environment puts special stress on
furnishings and finishes not seen in other building
types.
Fast response to new service needs is suddenly
critical
critical. As hospitals recruit key clinical staff and
strengthen their areas of expertise in response to
market conditions, hospitals are seeking truly fast
track projects, to get high-revenue and highly visible
services in place as quickly a possible. Hospitals
with urgent needs for complex new imaging
equipment or specialized services to support newly
added staff are finding that the financial realties have
made accelerated design and premium-time
construction efforts essential. To deal with these
situations the hospital needs the support of
experience facility program managers and a
systematized approach to design standards, interior
design, and patient flow issues, since there is often
little time to investigate options and develop a
measured response. When each room may
generate significant monthly revenue once it comes
on line, every week becomes critical.
Upgrading to meet new technical standards is
driving many hospital support services projects.
Areas such as dialysis suites and pharmacies,
which were constructed only recently, now need to
meet more rigorous standards for patient and staff
safety and infection control, which require more
extensive construction than merely a facelift.
Computerized order entry and tracking of supplies
requires something more than a simple storeroom.
High-productivity planning for surgery.
Hospitals with functional older facilities, often
scattered on different floors or in different wings,
are finding that it makes sense to invest in larger-
scale surgery facilities which are more productive
and more flexible. Some have created units with
20 or more generic operating theatres, directly
adjacent to highly flexible peri-operative units which
can function flexibly as pre-operative holding for
ambulatory patients and recovery for ambulatory
surgery and for inpatient. Rooms and recovery beds
are grouped in clusters, so that staffing can follow
peaks and valleys in the work load through the day.
Surgical rooms are designed for multi-specialty use
as needed, with very few dedicated rooms.
Operating theatres are also being rebuilt to include
facilities for minimal-access surgery and
telemedicine, with more flexible ceiling-mounted
utility booms, and new generation lights which
integrate efficient and flexible LED lighting, video
cameras and flat-screen technology. New hybrid
operating theatres blur the distinction between
surgical and imaging functions and design
requirements.
Responding to Emergency Medicine volume with
new care models is also driving major projects at
many hospitals. Often the Emergency Department
is the marketing front door and the starting point
for a high percentage of patient admissions, and
hospitals are very concerned about making it both
more productive and more responsive to patient
concerns. One common approach is the single-
room treatment concept, which provides a large
number of private treatment rooms so that each
patient and their family are usually taken directly to
one room for all of their treatment. Triage
steps are minimized, and much of the
admission process can be done directly in
the room. The result is a patient experience
of being seen and attended to almost
immediately, rather than the typical story of
being held in the waiting room for long periods
of time. Satisfaction is much higher and
flexible generic rooms can adapt easily to
changes in utilization. Reducing the need for
waiting room space allows for more functional
space.
Opportunities for bold master planning are
leading hospitals to look at their facility needs
in new and different ways. Instead of the
usual method of space programming and
master planning with an incremental view of
growth and space needs, typically resulting
in the classic hospital of many wings, each
10 years apart in delivery, new planning
considers ways to right-size facilities and
change the delivery process. Older
community hospitals are continuing the trend
toward mergers and creating more-efficient,
smaller facilities on a neutral site. Large
urban teaching hospitals are looking at
opportunities to replace inefficient older
buildings, consolidate operations, and in
some cases even replace the entire facility
with a new, smaller one that incorporates
higher efficiently and often lower staffing and
operational costs.
Taking a Fresh Approach to Hospital
Planning
Hospitals are unique among building
planning and design projects for their high
level of complexity, in terms of their complex
circulation patterns and constant use as
much as for their technical systems. By
definition, a hospital is a place where
healthcare services are delivered to patients
who may stay in overnight accommodations
or may visit briefly for specific care. The
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hospital as a unique building type is less than
100 years old. In history, hospitals were
generally charitable places where bed-ridden
patients could be cared for and given simple
treatments. At the start of the 20th century
new advances in radiology, aseptic germ
Queens Hospital Center’s Ambulatory Care Pavilion, New York. Corridor 1.
Image © Paul Rivera-Arch Photo. Courtesy: Perkins Eastman
theory, anesthetic surgery, and later
electronics and communications made the
former nursing care facility into a highly
specialized workshop for medical services.
The hospital took on a new physical form,
as a large dense building with many
specialized parts.
The ability to provide extended 24 hour care
with a high level of complexity of medical
services differentiates a hospital from other
healthcare facilities such as medical offices,
clinics, ambulatory care centers, day surgery
centers, skilled nursing and recovery
centers, and specialized treatment facilities.
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Successful hospital planning must be measured
over a long term, not just as an inviting and attractive
new building but as a structure that supports these
intensive and demanding functions on a 24 hour/7
day basis over what is often more than a 50 year
useful life.
Hospital Design Opportunities
Over this long period of use, a hospital is an
intensely people-centered building type in which
efficient circulation and the flexibility to meet
unknown future challenges are critical factors in how
well it supports these operations. Even a small
hospital is often one of the largest employers in its
community, with a staff of hundreds or thousands.
A hospital has to comply with many overlapping
regulatory requirements and voluntary accreditation
standards and is forced to constantly upgrade its
technology and its operational practices. With round-
the-clock use and high occupancy, and the need
for high capacity and redundant building systems,
a hospital is also a large energy consumer and a
prime opportunity for the benefits of green and
sustainable design.
Hospital Design Philosophy
As a place dedicated to health, a hospital building
must first be a healing, life-affirming space that plays
an active role in helping patients and their families
return to health. Hospitals of the future will need to
plan for higher patient acuity, shorter stays, and
must deal with aging patients (and staff). Because
of their long term operational costs and long life
cycle, hospitals have to be designed for improved
performance and work flow, and with a high degree
of flexibility and adaptability for constant change.
The detailed architectural and interior design
philosophy of the future hospital needs to start with
this feeling of hospitality, and of providing a link to
nature and the world beyond. The facility design
has to provide a safe, comfortable environment, and
reduce stress and confusion for patients, families,
and staff. A successful design will recognize the
dimensions of life as well as the needs of efficient
operations and include art as well as technology.
The design team needs from the outset to plan for
sustainable design and reduced energy usage,
which in a building that operates continuously is a
major opportunity for lowering the carbon footprint
of the service. To maintain a feeling of well being
and positive support for the needs of people, the
hospital must also have clear, intuitive way finding
and an easily understood layout.
5 Key Hospital Design Goals
Clearing the decks for a new approach to the ideas
of hospital planning begins by keeping five key goals
firmly in mind:
Patient-centered care and family as part of the care
process, since the patient is the hospital’s reason
for being
Efficient operations, clinical safety, optimal
functional relationships, value for money, modern
systems, low upkeep requirements
Flexibility for expansion and new technology
in unexpected ways over long useful life
Sustainable design, reduced energy usage,
intense 24 hr use and high occupancy
Healing environment to include art and
hospitality, not just science and technology
Planning for Building Systems
Hospital circulation systems are critical not
only to provide clear and intuitive way finding
for families and patients, and to
accommodate the many staff members and
services, but also for infection control,
carefully designed to separate and control
public and private, clean and soiled traffic
types. Planning is made more complex by
the many functions which need specific
adjacencies and short travel distances, while
at the same time controlling and directing
traffic flow. In planning the hospital, a logical
and simple horizontal and vertical circulation
system is the essential framework for more
detailed planning.
The nature of healthcare services is that
relatively small rooms need to be provided
for very specific functions, kept closely
adjacent to related services and well apart
from other functions. A typical hospital may
have only a few grand spaces, but thousands
of small rooms and large amounts of
circulation space. The space program which
guides the development of a hospital is often
a document detailing the room by room space
needs, planning assumptions, projected
activity volume, factors for efficiency and
circulation, and detailed medical equipment
needs. This schedule of accommodations
required is based on all of these factors, not
only on guidelines in terms of space per bed.
Hospital buildings also have extensive
mechanical, electrical, plumbing and medical
gas systems whose needs drive architectural
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planning as well. Each of these services
needs significant space for its equipment,
and benefits from the shortest and most
direct distribution while keeping building
services out of sight and separate from the
clinical and public areas. Structural design
for future hospitals emphasizes a high
degree of flexibility to accommodate planning
requirements that change all through the
design process and interior layouts which
can be expected to change many times over
the years. To deal with these systems,
modular planning within a consistent
structural grid can be established early in the
planning process to lend order to the result.
Unlike other building types, such as schools
and housing, which remain unchanged for
most of their useful life, hospitals must be
able to accommodate repeated waves of
expansion and renovation as needs and
technology change. Most hospital campuses
see a series of new or renovated facilities
every five or ten years, but with different
services turning over at varying rates. From
the beginning, the planning process must find
ways to manage this need for change and
to allow flexibility to meet new requirements.
Planning for Low Upkeep
A major challenge worldwide is to find the
right balance between simple, easily
maintained materials and building systems
which can be used over a long project
operating life and the need for open planning
which allows flexibility and change in
unpredictable ways over that long term. Floor
and wall materials need to be durable and
easily cleaned, yet the location of partitions
and doors will almost certainly change in
many areas of the buildings, so the
construction method needs to accept that.
Even simple hospitals will now have
extensive data and web-based
communication and control systems, yet the
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components have to be easily obtained and access
to them needs to be simple and clear.
Some low upkeep choices go back to the idea of
keeping the hospital as simple as possible- use of
more natural ventilation when possible eliminates
both ducted systems requiring upkeep and the
suspended ceilings needed to conceal their
systems. More use of daylight can reduce the
number and complexity of light fixtures, and new
types of fixtures such as LED lighting can have
longer life and lower maintenance costs. Durable
finishes simplify cleaning and replacement.
Five Types of Hospital Space
For all of these reasons, future hospital planning
starts with information from the organizer about the
proposed operational plan and numbers of
procedures and services, projected forward into
space needs and relationships. Planning also needs
to consider the very different needs of the five key
components of hospital space:
Inpatient Care: The word “hospital” brings to mind
an immediate image of patient bedrooms and the
nurses attending them, and while this is still a critical
element recent changes in technology have meant
that most healthcare services are delivered in other
parts of the facility. Patient rooms and nursing units
have been the subject of most research into hospital
design, over the last 50 years, and new data has
led to “evidence-based” design which is really a
shared understanding of design elements which
reinforce intuitive choices: patients in bed recover
faster and feel better if they can have their family
with them, have more private space and amenities,
and have views of nature and the outdoors.
Evidence has also shown that nurses work better if
given decentralized work stations near the patients,
which reduces their travel, and that single patient
rooms where feasible offer more flexibility for levels
of care and more privacy, while reducing patient
transportation and transfers. Although patient length
of stay is often less than it used to be, this is still a
longer term occupancy whose use is measured in
days, not in hours.

Hudson Valley Hospital Center – ICU Patient Room.
Image © Sarah Mechling-Perkins Eastman; Courtesy: Perkins Eastman
The architectural form of the inpatient component
reflects these functional needs: compact blocks of
patient rooms or wards with associated
decentralized nursing support, not the long corridors
of traditional hospitals, and with a high amount of
building perimeter to allow maximum patient room
windows. Groups of patient units can share
centralized support spaces, such as conference and
staff facilities, but each unit needs close by space
for medications, clean supply and soiled disposal
rooms, staff charting work stations for physicians
and non-nursing staff, and adequate storage for
supplies and equipment. Because the patient rooms
are continuously occupied, their orientation in terms
of the sun and the environment is important.
New directions in patient ward design are driven
as much by financing systems and cultural
expectations as by medical practice. When the
payment system supports more staff and more
generous use of space, the current trends, and
latest regulatory requirements, are moving toward
larger private rooms which can be adapted from
intermediate step down care to longer term care,
with optimal infection control and with amenities
such as private toilet and shower, entertainment
and communications, and visitor accommodations.
With larger private patient rooms, there is greater
flexibility to meet changing
equipment needs, and the long
term plan is that while these
units will be periodically updated
and refreshed they are not
appropriate to be renovated for
other uses due to their
specialized layout. In
subsidized healthcare systems,
where two-bedded rooms or
larger multi-bed patient wards
are still the norm, there is still
an expectation that patient and
family centered care and a
healing environment are still
important goals.
Inpatient care areas are very specialized
spaces, which are not easily used for other
purposes, although they are often
cosmetically renovated over the years of use.
When the need for more beds to support the
hospital’s business plan is well developed,
inpatient units usually expand in increments
of the bed tower, usually several floors of new
nursing units, often 10 or more years after
the previous project.
Bed units are grouped by an efficient number
of beds for most effective nurse staffing and
shortest traffic flow for staff, usually from 24
to 40 beds. Patient rooms need to be located
with views to nature and in consideration of
climate and environmental needs, and of
local codes. For example, some health codes
require a high percentage of patient rooms
in Northern Hemisphere countries to face
generally south for maximum sun, while in
hot climates the opposite may be required.
Nursing units need to be separate from public
areas, traffic restricted to staff and visitors,
and no traffic through one unit to reach
another. Within the unit separate visitor and
staff/patient traffic needs to be considered,
especially at elevators.
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The layout of nursing units must provide clear With current trends toward new, less invasive
and separate circulation for clean and soiled methods of care and treatment, in most hospitals
materials to support services such as food an increasing share of patient care is done on a
service, materials management, pharmacy walk-in, one day basis, rather than as an inpatient
and laundry. Since patient movement to and stay. Because these are short duration services and
from other services is not frequent, close patient and family convenience is a big factor,
elevator connections are acceptable but ambulatory care functions need to be close to
critical care beds should be on the same level parking and a point of entry.
adjacent to Surgery to simplify transportation
of these patients as quickly as possible. In Since most ambulatory care services are delivered
the interest of greatest flexibility, it is by one or two professionals, meeting with a patient
generally better to locate all critical care unit and possibly a family member, the space need is
types together on the same levels if possible, for many small encounter rooms with low technology
rather than trying to relate ICU bed types and needs which can be fairly standardized. Efficient
related step down acute bed on the same operations and patient flow are very important, so
levels. Inpatient units need fairly direct to maximize the efficient use of space the trend is
access to diagnostic and treatment services, to create modular groups of rooms for examination,
efficient support services access, but should consulting, and treatment which can be used by
be separated from ambulatory care areas different services as needed from one session to
and back of house support areas. the next. Each module typically has a reception and
registration work area, nearby waiting for post-
Ambulatory Care Care: As the opposite of registration patients and their families, a block of
inpatient care, care for walk-in ambulatory identical exam and consulting rooms, and shared
patients is the fastest area of growth in support for staff functions. A two-sided layout keeps
healthcare services. New technology and patient traffic and staff traffic into the modules well
new diagnostic tools have made this much
apart and lets staff come and go without passing
more than a traditional clinic facility.
through patient areas. Each exam room is carefully
Ambulatory care is now the approach of
worked out to balance patient privacy and efficient
choice, with inpatient admission only as
staff work areas, with needed supplies close at hand.
necessary for continued care or
diagnostic and treatment
services. While patient and
family-centered care is a
growing trend, unlike inpatient
care the length of stay for each
encounter is a matter of an hour
or two, not days, so efficient use
and flexibility are very
important. Even with these short
contacts, an orientation to
nature and a healing
environment improve the
experience, so whenever
possible exposure to natural
light and ventilation can provide
an inviting human-scaled Examination Room, New York Congregational Nursing Center.
space. Image © Sarah Mechling-Perkins Eastman; Courtesy Perkins Eastman.

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Evidence has shown that errors are minimized when
facilities are similar, so in many current plans all
exam and consultation rooms are identical, with
same-handed layouts in which repeatable staff
procedures are more important than backing up
plumbing risers.
Ambulatory care modules are planned to provide
light and views where people spend most of their
time, in the waiting areas and in staff offices behind
the patient contact area, not in the exam rooms as
a first priority. To accommodate this modular
approach to planning, large wide floor plates work
better than narrow wings, so they often take the
form of deep spaces with parallel front and back
circulation systems to separate patient and staff
traffic. Patients are often referred to other diagnostic
services after their initial examination or treatment,
so the ambulatory area needs to be closely adjacent
to functions such as Diagnostic Imaging and Non-
Invasive testing. Because this is a relatively fast
turnover function, the ambulatory care entrance
should be convenient to parking and patient arrivals
and separate from other hospital public and visitor
and inpatient areas.
In order to get maximum efficiency in the use of
this space, the current best practice is to organize
services in modular units, each of which has
standardized waiting, reception, exam, consultation
and office areas. Each unit has patient access from
one end, and private staff circulation at the other,
without having to pass through patient areas.
Instead of being organized as separate clinics, each
the territory of one service which may use them
only part time, adjacent modules can be shared to
accommodate peaks of usage by overflow into the
next module, while from the patient perspective
there is one point of reception and one waiting area
for the service.
This modular layout works best with large blocks of
flexible space, requiring windows at the public and
staff ends but not for most exam rooms. Large
programs of ambulatory care may have multiple
floors or pods of similar modular space. Diagnostic
services need to be accessible nearby, for referral
of patients, but need not be directly adjacent.
Ambulatory care needs convenient access
to patient and public services, such as food
services, registration, and amenities, but
should be apart from inpatient areas and from
back of house support.
Ambulatory care often grows by expansion
with more modules, rather than by
renovation, but this simple low-technology
space can be fairly easily revised as needed
later.
Diagnostic and Treatment Functions: In
addition to the direct care of inpatients and
ambulatory patients, hospitals routinely
provide centralized technical services to
assist in the diagnosis and treatment of
patients, which need to be accessible easily
to both types of patients without mixing the
two. As in direct healthcare, the essence of
the program requirement here is for relatively
small, highly specific rooms in which specific
services are performed.
Diagnostic functions, to help identify the
cause of a disease or condition, often include
Imaging (X-ray, CT Scan, MRI Scan, Ultra
Sound, and Mammography), Clinical
Laboratory services, and Non-Invasive
testing (EEG, EKG, Stress Test, Nuclear
Medicine). Treatment functions may be
invasive (Surgery, Endoscopy, Interventional
Radiology, Biopsy, all with patient preparation
and recovery areas) or non-invasive services
such as physical medicine and respiratory
therapy. All of these services have similar
program elements- patient registration,
waiting, dressing or preparation, staff work
areas, office space- and a similar pattern of
separate patient and staff circulation.
A current planning trend to provide more
flexibility and more efficiency of operations
is to group related functions by type of use,
cutting across departmental lines. For
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Cath Lab: NYU Medical Center’s Cardiac and Vascular Center.
Image © Sarah Mechling-Perkins Eastman; Courtesy: Perkins Eastman
example, patient holding and recovery functions
can be located together, with the number of
staffed observation beds able to expand and
contract as needed during the day, to serve a
variety of functions. Interventional services, which
require sterile precautions and a restricted area
with special HVAC and electrical services, such
as Surgery, Endoscopy, Interventional Radiology,
Interventional Cardiology, and Intra-Operative
Imaging can all be part of one larger suite which
shares specialized support functions such as staff
locker rooms, Central Sterile Supply, clean supply
and decontamination, rather than creating several
similar suites.
Planning for diagnostic and treatment functions
typically requires large blocks of space with
multiple circulation paths to separate patients,
staff, visitors, clean, and soiled traffic. While
natural light is desirable in waiting, patient
recovery, and staff areas, it is often not permitted
in areas which require rooms with controlled
lighting and special environments. In order to
facilitate fast and easy access between related
functions, for example Emergency, Imaging, and
Surgery, vertical stacking may make sense as
opposed to spread out horizontal areas.
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Flexible construction and
planning for future renovation
are most important in these
diagnostic and treatment areas,
where changing equipment
needs and the frequent addition
of new technology and new
services require very
specialized rooms to be
adapted to house extremely
costly equipment. The overall
structural envelope for these
spaces needs to be optimized
for flexibility, not specifically
tailored to current practices
which may change in
unpredictable ways. One
important approach is to plan for soft, non-
technical space between highly technical areas,
to provide a cushion to absorb future space needs.
Mechanical and electrical systems in these areas
also need to be highly flexible and adaptable.
Some rooms, such as MRI and CT imaging rooms,
require large and heavy pieces of equipment
whose future removal and replacement needs to
be accommodated. In almost all areas, a current
trend is to utilize ceiling-mounted movable booms
to provide electrical, medical gas, and equipment
at the patient location, which requires a structural
system which has the flexibility to support
overhead equipment at almost any location and
can be easily modified later.
The major services, such as Emergency, Surgery,
Imaging and Lab are self-contained units which
each have their own internal needs in terms of
functional adjacency and circulation. In general,
each has a public side, for ambulatory patients
and their families, and patient circulation which
need to be kept separate from inpatient traffic on
stretchers and staff circulation.
Emergency needs a close horizontal connection
to Diagnostic Imaging, and a secondary
connection which is usually vertical to Surgery,
where patients are sometimes transferred after they
have been stabilized. Imaging also needs to be
accessible to ambulatory patients, but not usually
with direct transfers from the ambulatory care area
to imaging; this is seen more as two visits, which
may or may not occur on the same day. Other
interventional services such as Endoscopy and
Catheterization Labs or Interventional Radiology are
well located adjacent to Surgery, where they may
be able to share patient preparation and recovery
areas and staff facilities.

Non-invasive testing, such as EEG, EKG, Stress
Test, Nuclear Medicine, and Biopsy, is well located
near Imaging which also deals largely with
ambulatory patients. Clinical lab patient contact
functions, such as blood drawing and specimen
collection, need to be accessible to ambulatory
patients, but the analysis and processing functions
of the laboratory, which are now often automated
high volume services, are well located away from
public access and linked by pneumatic tube or other
systems. While access is needed for clean and
soiled materials from support services, diagnostic
and treatment areas should be located generally
away from both public and back of house support
areas.
Support Services: The fourth element of hospital
services is the less-technical space which supports
the other functions, with the ability to deal with the
needs of patients, visitors, and staff members and
traffic which vary over the 24 hour, 7 day cycle of
hospital operations. Support services include staff
facilities such as lockers, education and training,
on-call rooms for on-site medical staff, lounges and
staff rooms for employees who often cannot leave
their work areas for breaks, and overall
administration and office activities.
They also include back-of-house hotel type services
such as dietary kitchens and services, materials
management for clean supplies and equipment,
pharmacy services, housekeeping, loading bays,
waste management, and engineering and
maintenance functions. Separation of circulation,
Radiology Procedure Rooms: Cardiac and Vascular Center,
NYU Langone Medical Center. Image © Sarah Mechling-
Perkins Eastman. Courtesy: Perkins Eastman
for clean and soiled materials, is an important
consideration, and so is efficient distribution-
staff time is the largest expense in the life
cycle of a hospital, so inefficient distribution
is a cost penalty which keeps increasing over
time.
Many of these support functions, unlike the
spaces where medical care is delivered,
utilize larger rooms and large blocks of
space, but no daylight is needed for most
supply and support functions. These areas
are usually a very low priority for later
renovation and expansion, unless the overall
scale of the hospital has changed
dramatically.
Support functions need their own direct
access from an industrial loading dock, well
apart from visitor and patient traffic, with good
vertical connections to inpatient and
diagnostic and treatment areas. Often, staff
facilities such as lockers, education and
training, and employee health are part of this
area but with their own entrance convenient
to staff parking and public transportation.
Public Spaces: The fifth type of space is the
cultural and emotional heart of the hospital,
and the element of design which lifts it from
being a technical clinical service to being a
healing place. Public functions include

11
entrance lobbies, atriums, meeting places,
visitor and family accommodations, food
services, amenities such as shops and public
services, and access to administration and
registration functions. Public access is also
needed for conference centers and health
information and library services. Public
access, from convenient parking and pick
up and drop off areas, needs to be well
separated from service functions and loading
areas. Visible and clearly identifiable large
volume spaces are needed for major public
functions, and are typically one of the slower
areas to be expanded or renovated as
services increase.

The public portion of this service, such as

lobbies, atriums, shops, conference center,
café and food service, registration and
finance, needs to be highly visible to arriving
patients and visitors and close to parking and
arrivals, with the flexibility to handle large
numbers of people at peak times and for
special events; natural light, a relationship
to the outside world, and clear wayfinding
are all important. Directly adjacent to these
public spaces are the principal ambulatory
care area, access to major diagnostic
services such as Imaging and Noninvasive
testing, and visitor access to inpatient
nursing units. The public zone should be
separated from major treatment functions
such as Emergency and Surgery and from
support services.
Relationship of Spaces
Atrium Winter Garden: St. Vincent’s Medical Center’s Cancer
Center. Image © Chris Cooper. Courtesy Perkins Eastman
demanding functional needs of a hospital are best
served by architecture which is planned from the
inside out, rather than fitting program elements into
an overall form. The room by room functional nature
of healthcare services means starting with the
necessary plan for one room type, with its equipment
and relationships, then building that into functional
planning modules, departmental zoning, and finally
the overall stacking of the building mass where
functional flow and architectural balance and design
all need to coexist.

Whether it is a large academic medical Modular Planning

center or a smaller community hospital or
rural healthcare facility, the form of a hospital
needs to derive from the functional
relationships which are essential to the
efficient operation of a very specific 24 hour/
365 day service, with overlapping functional
needs. Unlike some other building types, the
Recent experience in medical planning by large
healthcare organizations has shown the value of
working within a standardized typical planning
module to organize a flexible structure that can
adapt to future needs. Hospitals of 50 years ago
reflected the planning assumptions of the times, that

12
narrow wings of patient rooms were desirable to
allow for natural ventilation, and that once planned
the hospital’s diagnostic, treatment, and support
areas were relatively static. Current thinking is quite
the opposite; while patient units take a form specific
to their function, and are seldom modified for other
functions later, the rest of the hospital needs to be
easily adaptable and expandable without disruption
to ongoing operations. The discipline of an overall
planning module encourages these kinds of
alternatives.
Worldwide, the trend is toward an overall hospital
planning module that can accommodate either a
large ward or pairs of patient rooms, groups of
typical exam rooms, one large special purpose room
such as an operating room, or groups of structured
parking bays. For flexibility and economy, the
module needs to be part of a simple and cost-
effective structural system, and one which permits
later changes and modifications easily.
One frequently used planning module that fits these
criteria is a bay size of 9.2 M x 9.2M ( 30 ft) which
neatly fits a cluster of 6 exam rooms with a 1.6M
(5ft)corridor, or two patient rooms with a nominal
width of 4M (13ft), or a group of 6 parking spaces.
This size module also is within the capacity of a
minimum depth flat slab concrete structure or a
simple steel structure, without long spans.
Planning for Hospital Expansion
Expansion occurs in increments, whose size and
typical frequency of change vary by type of function.
Inpatient Space generally expands in multiples of
typical nursing units, as the need for beds increases
due to changes in population of services. Changes
in the number of beds are a major change to all
hospital services and to the business plan, and there
is a logical cap on beds for most hospital sites;
beyond a certain level it makes more sense to build
a new inpatient hospital some distance away, rather
than to create a very large number of beds on one
site. Inpatient additions may occur in waves 10
years apart, even in times of fast growth,
given the time needed to confirm demand,
make business plans, and design, finance,
and construct large expansion projects.
Ambulatory Care also expands as to meet
an increasing volume of patient visits, but the
change is seen more quickly than bed need
and is easier to plan for. Expansion usually
occurs as a multiple of clinic modules and
even in times of fast growing volume may be
on a 5 year span between additions, given
the time to plan, design, and execute.
Diagnostic functions change more quickly,
with frequent new and improved technology
which requires smaller and faster incremental
changes. Expansion or more likely
renovation may happen almost continuously
as projects are identified and funded, and
diagnostic expansion is limited by functional
distance relationships, not just site
conditions. Projects are often small, involving
a cluster of rooms or a change of technology
in one existing room.
Treatment Functions expand more slowly.
Changes in treatment services, such as
Emergency, Surgery, or Cancer Therapy are
major changes in the business case and
need substantial advance planning before
reaching the design stage. Expansion or
renovation of these services is a major
project which occurs in large blocks of space,
where functional relationships need to be
maintained and existing services must not
be disrupted.
Support Services expansion is infrequent and
even large increases in beds and services
may not need similar changes in support
services. Expansion occurs in medium size
blocks of space for functions such as food
service or supply services, if at all.
Outsourcing of services may be considered
to preserve space on site for critical functions.
13
Public Space expansion for major public
spaces such as lobbies, atriums, and
amenities is often the lowest priority for
expansion other than cosmetic change.
Revising and expanding public spaces is
usually part of a major master plan and
change in direction. Understanding these
different ways in which hospitals grow and
change is a basic first step toward planning
for successful future expandability.
The future hospital: A Logical Planning
Approach
Because a hospital is by definition all about
people and movement, planning has to start
with circulation systems as a basic
framework for any concept:
l The main public entrance needs high
visibility and easy access, leading to
the main public space
l An outpatient entrance, also visible
but separate from inpatient and visitor
traffic, leads to ambulatory care clinics
l Emergency Medicine needs a
separate away from public traffic, but
convenient to outside access
l The service entrance and loading
bays need to be easily accessible but
out of public view
l Drop off and parking needs to be
conveniently provided for all types of
traffic
l Hospital staff parking, separate from
patients, needs to be close to a 24
hour entry
As each of these layers of circulation is
added to the plan, the logical form of the
hospital begins to take shape, with different
types of traffic approaching from different
directions and vertical circulation finding its
place as logical nodes along the circulation
grid.
14
Provide Right-Sized Space for Hospital
Functions
Hospital space needs are directly related to
operational and business planning assumptions,
and need to be based on projected activity volumes
and basic elements (not just SM/per bed). For each
type of space, this analysis depends on days of
operation, time per activity, and the size of rooms
and support space needed for the activity.
For example, if ambulatory care visits take an
average of 1 hour, including time to turn over the
room between patient visits, and if the program will
operate 5 days per week, 50 weeks per year, with
an 8 hour working day and 80 % utilization as a
target for operations, one exam/consult room has a
capacity of: 5 days x 50 weeks = 250 days; 8 hrs x
250 days =2000 hours available; 80% utilization
=1,600 visits per room per year. If each exam/
consult room is typically 11 SM, and for each
working room there needs to be an area of about
60% for support space and local hallways, the
number of annual visits per SF for exam/consult
module areas would be: 11 SM x 160% =18 SM to
do 1,600 visits per year, or about 89 visits per year
per SM. A business plan that assumes 85,000
annual visits (340 per day, on average) would need
about 955 SM of exam/consult areas, plus waiting,
reception, and other related functions.
Clearly, changing each of these assumptions
changes the end result in a very transparent way.
Similar analysis of procedures and the spaces
needed for them can be done for almost all
functions, from Surgery, Emergency, and Imaging
to inpatient beds and support services. It is also
possible to project future growth in services to
provide at least space on the site for future
expansion that seems probable, even if not
constructed in Phase One.
With a Functional/ Space Program which
summarizes all of these working assumptions, the
design team can add functional blocks of space to
the circulation framework, for each of the key types
of space:
 l Inpatient Care Units
l Outpatient care
l Diagnostic /Treatment
l Admin/ Support Services with loading bay
l Public space and lobby
Organizing Key Functional Relationships
Shaping quantities of space needed into a logical
hospital starts with a modular planning grid which
allows flexible uses and shifting of functions later,
within a basic structural system. Decisions about
the vertical stacking of the spaces, to fit the site
and to make circulation more efficient, consider the
basics of hospital organization:
l Provide ground level access for public,
outpatients, ER
l Provide horizontal or vertical circulation
between critical services
l Consider distribution of support services and
separation of traffic types
l Even with a very large site available, efficient
travel distances for patients, visitors, and staff
often suggest a multi story plan for at least
some services. Outpatient clinics, which
share a common arrival point and patient
services, but only a limited relation to each
other, are often grouped into an ambulatory
care building adjacent to but a bit separate
from the rest of the hospital, possibly even
with a simpler business- occupancy type of
structure. Inpatient units are often stacked
for the same, reason, since they have limited
connections with each other but need very
close and convenient access to diagnostic
and treatment services. Emergency needs
to be horizontally adjacent to Imaging, if
possible, for easy patient movement, but can
be vertically linked to Surgery and ICU which
should be adjacent to each other.
Planning for Variable Speed Expansion
The key to a flexible and expandable hospital
is to recognize it as an open system, in which
each element has a place to grow at its own
rate without disrupting others and without
changing the efficiency of the overall hospital.
This systems thinking will allow the hospital
to adapt to a changing business case, as the
need for services and the ways in which it
addresses the market change in unexpected
ways. The goal is a flexible and expandable
facility which remains scaled to needs of
people in a clear and hospitable way, even
as it goes through changes over its long life
time.
The short history of the hospital as a building
type, over less than 100 years, has shown
that it is not possible to set out a Master Plan
for growth based on assumptions which will
change in unknown ways. For example,
hospitals of 1920, 1960, 1980 and 2008 each
had a Radiology department, later better
named as Diagnostic Imaging, with radically
different sets of assumptions. A hospital of
1980 planned for specific growth in radiology
imaging rooms would have missed the future
revolution in technology such as CT
scanners, MRI, PET CT, and digital imaging,
which have had a major impact on the use of
imaging services, the amount and type of
space needed, and how those services
interact with other hospital functions.
Hospitals planned with many beds, for a long
length of stay, now find themselves needing
to be radically downsized and in many cases
reconstructed, as patients remain in the
hospital for much shorter periods and the
nature of hospital services changes. A
hospital designed as a closed and perfected
architectural object, exactly tailored to its
program and initial planning assumptions, is
generally obsolete by the time it is open, in
some ways.
15
Allowing for variable speed expansion
means opening the door to unexpected
change but channeling it in controllable ways
to preserve overall functional relationships.
At the departmental level, planning for
expansion means using soft spaces to create
buffers between hard, technical, and costly
to change functions, such as locating easily
changed offices and storage areas between
two complex imaging rooms, to allow for
future change if needed but without investing
now in shell space which in itself makes too
many assumptions about future uses.
At the facility level, planning for expansion
means not stacking functional areas too
tightly and leaving some slack in the plan to
allow change to happen, without spreading
functions out inefficiently. At the site level, it
means projecting possible future growth
needs and creating flexible zones where
unplanned things can occur, while managing
the overall flow of activity on the site.
Expandability also recognizes that building
systems will have to grow and change, and
Emergency 60,000
Surgery 15,000
Imaging 50,000
Outpatient 200,000
Inpatients 18,000
228 Beds
22 ICU Beds
16
need to be accessible and have their own pathways
for growth. Organizing vertical circulation and
horizontal distribution of services in relation to the
overall planning grid provides a planning discipline
for the initial design and easily understood directions
for future change.
Example: A 250-Bed Future Hospital
To test some of these ideas for a very flexible and
expandable hospital, the authors started with a
typical program for a new hospital in an expanding
area, based on our work with many international
hospitals. Unlike long range strategic planning and
complex renovations of existing hospitals, a new
hospital puts the focus on clear and creative
thinking, rather than on dealing with the many
variables of an existing facility. The basic functional/
space program is typical for a hospital of this size,
based on some key planning assumptions:
Gross building space was targeted at 35,000 SM,
at 140 SM /bed. Space needs were estimated by
type of space, plus provision of 50 indoor parking
spaces for physicians and key staff:
visits/yr
cases/yr
procedures/yr
visits/yr
admissions/yr, 5 day Avg. Length of Stay
Medical, Surgical, OB/G, Peds, 6 units of 38 beds,
1, 2, 4 bed rooms
Medical/Surgical/Cardiac ICU, all private rooms
Building Program Summary by Type (SM)

(assumed program) dept gross % of gross

Inpatient Nursing 7,000 26%

Outpatient 3,800 14%

Emergency 1,400 5%

Diagnostic/Treatment 2,200 8%

Surgery/ PACU/ICU 3,200 12%

Clinical Support Services 2,400 9%

Operational Support Services 4,000 15%

General Support Services 800 3%

Lobby, Public Amenity, Retail 800 3%

Training & Education 800 3%

Staff Welfare 600 2%

Net Floor Area ( dept gross w/o factor) 27,000 100%

MEP Services 3,200 12%

Inter-Dept Circulation 4,100 15%

Total Dept Gross Area ( w MEP and Circ) 34,300 127%

Total Building Gross Floor Area -GFA 34,300 GSM

Basement parking @ 50 SM/ Car 2,500 GSM

Number of cars 50 cars

Gross Floor Area per Bed including parking 147 GSM

Other design goals were a mix of private and
subsidized ward types, with natural light and ventilation
used in many patient areas and non-technical spaces.
Outpatient clinics are scaled to projected volume, but
can be easily adjusted for other assumptions. In order
to provide flexibility of implementation, the goal was
also for a flexible plan which would permit phased
construction and expansion as needed, for example
building the ambulatory care center in advance of the
hospital itself, or building the 250 beds in two or more
phases as needed.
Analysis of these amounts of space required, and a
workable relationship between functions, suggested
a concept for organizing the building, shown here as
a stacking diagram which is just that, a diagram,
not a design Planning for this proposed hospital
starts with circulation; in terms of the number
of daily users, the Outpatient Pavilion entry will
be the one used by most of those who come to
the hospital; the Main Lobby entrance serves
inpatients being admitted, visitors to inpatients,
and administrative visitors, so it needs to be
separated from the higher volume outpatient
entrance, yet be able to share some amenities
and support services. Emergency patients
need a point of arrival well away from other
entrances, while staff and service functions
need private access of their own.

17
 Stacking Diagram Section-250-bed Future Hospital. Courtesy: Perkins Eastman

The resulting concept is a four-sided plan, clear and simple planning. Nursing units would have
with each of these main entrances on its own a mix of room types as appropriate to the patient
side. Each entrance is also linked to vertical mix: isolation rooms, private rooms or suites, or 2
circulation: smaller, faster
public elevators for outpatients
and visitors, patient/staff
service elevators for more
private hospital functions with
large capacity elevators.

The design concept stacks the

major functional spaces by
type, around a healing garden
courtyard which is the visible
center of the hospital.
Outpatient services are in a
three story block with a major
entrance plaza facing the main
street, and a building form
which is articulated to allow
natural light and ventilation to
all of the exam/consult rooms
in modular plan clinics. 3-D Diagram -250-bed Future Hospital. Courtesy : Perkins Eastman
Dedicated elevators or
and 4 bed multi patient rooms, each with adjacent
escalators link the clinic floors to the large
toilet/shower and space in the room for family use.
Outpatient Lobby and to a Medical Street
Where the climate permits, many of these rooms
with patient services on the ground floor.
can be naturally ventilated and the shallow width of
Inpatient nursing units are stacked on the the wings allows daylight in most patient spaces.
more private side of the hospital, further
Diagnostic and treatment services are in a block
away from the street, but looking out onto
spanning between the two bars of the inpatient and
the garden court and to green roof areas.
outpatient pavilions, accessible to both and able to
Each nursing unit is served by groups of
expand as needed on its own. This block locates
public and hospital elevators, organized for
Emergency and Imaging together on the ground

18
floor, Surgery, PACU, and ICU together on the
second floor, and on the third floor Labor/Delivery/
Recovery adjacent to Obstetrics/Gynecology,
Nursery, and Pediatric beds.
Hospital services are in a basement, served by a
loading dock accessed from the rear street,
organized for separation of clean and soiled
functions. A basement under the Outpatient Pavilion
accommodates 50 parking spaces for physicians
and senior staff with direct access up to the building.
This plan is designed for direct and intuitive
way finding for each type of user, and is able
to expand incrementally as needed:
Outpatient clinic modules can be added,
Diagnostic services can expand outwards,
and one or more additional inpatient nursing
towers can increase bed capacity. If
necessary, the project could be developed
in phases, with the Outpatient and/or the
Diagnostic block built first, and inpatient beds
and support services added later.

Massing Diagram-250-bed Future Hospital. Courtesy: Perkins Eastman

Massing Diagram - 250-bed Future Hospital. Courtesy: Perkins Eastman

19
Example: 600-Bed Urban Hospital
In a similar example, these concepts can be
applied to the design a new 600-bed hospital
for a developing area of a major city. The
design concept focused on the high volume
outpatient block as the main entrance, with
a large public plaza at the street where
patients wait for buses, taxis, and private
cars. A major planning issue was a local code
requirement for south-facing patient rooms
in two nursing unit towers with future
expansion as a third tower.
The proposed project located diagnostic/treatment
services as flexible space between the inpatient and
outpatient wings of the hospital, and created a
garden court as the heart of the hospital which is
visible from both the outpatient plaza and the Main
Lobby inpatient area.
Total program area was 72,000 SM, with 90
basement parking spaces and support services in
the basement. The architectural design features a
contrast between, the low, curved outpatient pavilion
fronting on the main street and the tall, brick-faced
inpatient towers behind it.

Columbia-Presbyterian Medical Center Circa 1940

RenJi Hospital, Shanghai, China: Rendering (Aerial). Courtesy: Perkins Eastman

20
Example: 500-Bed Regional Hospital A diagnostic/treatment block facing the
outpatient pavilion across the garden
In a similar test of the concept, similar ideas are
accommodates Emergency, Imaging,
the basis for a proposed large regional medical
Surgery, Recovery, ICU and Labor/Delivery
center, to be built in a semi-rural site. The design
and postpartum care. Its roofs step back to
brief requires 500 beds, including VIP and ICU beds,
create a series of roof garden terraces, which
expandable in future to up to 1,000 beds, plus a
are linked with sloped trellis planting walls to
large scale ambulatory care service and a major
the main garden below.
emergency service.

Two basement levels house hospital

Once again, planning began by recognizing the
Outpatient block as the main entrance for most
patients, located to be clearly visible to traffic
entering the site. An iconic inpatient lobby, with a
distinct sloped oval form, provides separate access
for visitors and patients being admitted, linked to
the large Healing Garden courtyard and elevators
to patient units. The visitor lobby there overlooks a
scenic river, toward which the gracefully curved
nursing units are oriented for sun and views. The
top floor of one patient tower houses a unit of VIP
patient suites and ICU suites, which also share
private elevator access to a VIP outpatient clinic
and lobby at the ground floor.
services, receiving, and parking for 600 cars.
Staff housing is provided on the site for a
mix of senior consultants and clinical staff.
The hospital is planned for possible
expansion up to 1,000 beds to serve this
growing region; a second bed tower with two
curving wings of rooms oriented toward the
river can be built on the other side of the
outpatient and diagnostic blocks, and each
of those can be separately expanded toward
the end as needed.

301 Peoples Liberation Army Hospital and Health Resort, Sanya, China,
Rendering (Aerial). Courtesy : Perkins Eastman.

21
 301 Peoples Liberation Army Hospital and Health Resort, Sanya, China.
Hotel Waterfront, Rendering. Courtesy: Perkins Eastman.

A Way Forward for Future Hospital
Design
In developing these ideas, it was very
important that this new concept should not
be a recycled North American or European
hospital plan type, but should focus on the
basic ideas which need to drive hospital
planning worldwide. The result is not a fixed
design, but is an approach to planning which
can be applied at different sites and in
different sizes. What is most important is to
focus on a planning process leading to form, not on
designing an architectural idea first. It was also
critical to think in terms of an open system of
planning, in which variables such as required
services, anticipated volume, operational and
staffing assumptions, and building system decisions
could all be adjusted and tuned as needed while
keeping in mind the basic goal of a high quality, low
upkeep, flexible and expandable hospital concept
which can be an expression of a new hospital type
for world use.

22
Chapter 2
Hospital Building
Project
G. D. Kunders
Development Phases of a Hospital Building Project
Feasibility study / Survey
Financial planning &
Fund raising
Appointment of CEO and /
or Hospital Consultant
Appointment of Architect
Site analysis & Selection
Schematics
Design development & Interiors
Construction drawings &
Specifications
PRELIMINARY STUDIES
& FUNCTIONS
Operational & Functional Assessment of project Select contractors, suppliers &
planning quipment needs services
Cost efficient layout & Evaluation of best equipment Building contract & documents
Planning Maintenance & service Monitor all construction activities
Mechanical systems procedures & records
Cost management &
Construction systems Procurement of equipment & administration
supplies
Working drawings & Coordinate construction phases
Specifications Incoming Inspection &
Instrument control Taking over of the facility-
Tender documents formalities
Procedure
Contract negotiations Trial run of hospital
Training of operators & other staff
Commissioning of the facility
Start up & commissioning
Inauguration
PLANNING AND DESIGN
EQUIPMENT EVALUATION, PROJECT MANAGEMENT
SELECTION AND AND COMMISSIONING
COMMISSIONING
SYSTEMS DEVELOPMENT
STAFF RECRUITING & SELECTION AND MANAGEMENT
ORIENTATION & TRAINING
MANAGEMENT OF
HOSPITAL SERVICES
Recruitment & employment policies
Management & operation
Information Employee service rules Management, financial, technical
Accounting systems & Compensation policies: salary structure, systems & controls
financial controls benefits
On-going facility management
Biomedical engineering & Performance evaluation & other systems
maintenance Qualified recruiting staff Quality assurance programmes
Purchasing, stores Recruitment, selection & placement Patient services
management & Inventory
control Orientation/ indoctrination
Human resource management
Training & development
Medical records
Trial run of facility with staff in place Material management & supplies
Patient services
 Different Stages in the Construction of a Hospital Building

01 Commencement certificate 16 False ceilings

y)
02 Demolition (if necessary 17 Interior walls
03 Site preparation / grading 18 Waterproofing
04 Layout and marking 19 Hard interior
05 Footings 20 Floorings
06 Foundations 21 Paint and Finish
07 Structure 22 Built-in (fixed) equipment
08 Floor and decks 23 Depreciable equipment
09 Walls 24 External services
10 Windows / Doors 25 Landscaping
11 Electrical work 26 Testing and commissioning
12 Plumbing 27 Trial run
13 Water supply and sanitation 28 NOC / Certificate of occupancy
14 HVAC 29 Takeover by the owners
15 Fire detection and protection 30 Move in.

Building Project Time Schedule

2 1
5 Months 3 Months 8 Months 6 Months 18-24 Months
Months Month

Programme
Approved

Schematics

Statutory
Approvals
Design
Development
Contract
Documents

Bidding

Working
drawings

Construction

24